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Electrocochleogram and Perilymphatic Pressure Measurement
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This policy governs Aetna's coverage and medical necessity criteria for electrocochleography (ECOG) and measurement of perilymphatic pressure for diagnosis and management of inner ear disorders, and identifies investigational uses. It applies to Aetna members and participating providers.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
inv-01: Medically Necessary Indications
Aetna considers electrocochleography (ECOG) medically necessary when either of the following applies:
From policy medical necessity section
inv-02: Experimental/Investigational (Not Covered)
The following are considered experimental and investigational (not covered):
Policy lists these as experimental/investigational
inv-03: Evidence-based findings (no insurer criteria specified)
Summary of systematic reviews and cohort studies
inv-04: Documented clinical uses / evidence
Clinical contexts in which ECoG/perilymphatic pressure measurement have documented utility or are described in the literature:
See feasibility and mixed outcome correlations in CI studies
Adams et al, Park et al and related studies
Historical use for hydrops; perilymphatic pressure measurement not supported by studies
The policy lists specific ICD-10 codes that are appropriate when ECOG indications are met and also identifies codes that are not covered for the indications in this bulletin. Covered ICD-10 ranges include codes for Meniere's disease (H81.01–H81.09), various vestibular disorders and vertigo (H81.10–H81.13; H81.311–H81.49), labyrinthine fistula (H83.11–H83.19), sensorineural and mixed hearing loss (H90.* series), sudden idiopathic hearing loss (H91.20–H91.23), tinnitus (H93.11–H93.19), and symptom codes for imbalance and dizziness (R26.89, R42).
The bulletin also identifies ICD-10 codes not covered for the indications listed, including S09.91xA–S09.91xS (unspecified injury of ear [cochlear trauma]) and routine screening encounter codes Z01.10 and Z01.110 (encounters for ear/hearing examination without abnormal findings or for follow-up screening).
Within the material reviewed there are no additional explicit exclusion conditions or clinical scenarios stated beyond the ICD-10 not-covered examples. The document summarizes study findings, feasibility, and limitations of ECOG and perilymphatic pressure measurement but does not specify further insurer-level exclusion criteria.
ECoG abnormalities such as an elevated SP/AP ratio are not unique to superior semicircular canal dehiscence. The policy notes that elevated SP/AP ratios have been reported in other inner-ear conditions including Meniere's disease and perilymphatic fistula, and therefore ECoG findings are not specific for canal dehiscence without correlation to imaging and other clinical tests.
This Clinical Policy Bulletin is intended to assist in administering plan benefits and provides a general description of coverage considerations. It does not constitute an offer of coverage, a contract, or medical advice. Providers should verify member eligibility, benefit coverage, and any prior authorization requirements with the plan and remain solely responsible for medical management of patients.
Published reports do not support the use of perilymphatic pressure measurement as a diagnostic tool for Meniere's disease. Multiple studies cited in the bulletin concluded that perilymphatic pressure measurements did not differ significantly between affected and unaffected ears or between patients and normal-hearing subjects, and the technique was considered not useful for evaluation of Meniere's disease.
Systematic reviews and case series show that intraoperative ECochG recordings can be obtained in the majority of patients (>90%), but the ability of intraoperative ECochG changes to accurately predict post-operative hearing loss is limited. Across studies there is notable heterogeneity in definitions of signal disturbance, recording techniques (extra‑ vs intra‑cochlear), and outcome correlations, resulting in limited sensitivity and specificity for prediction of long‑term hearing preservation.
Conflicting findings and limited interpretability of intraoperative ECochG response changes have impeded widespread clinical adoption. Intra‑cochlear electrode movement relative to signal generators complicates interpretation, and investigators have recommended simultaneous extra‑cochlear recordings and attention to phase shifts and harmonic distortions to help distinguish traumatic from non‑traumatic signal changes.
Billing Codes and Diagnostic Thresholds
| 92584 | Electrocochleography |
| 69930 | Cochlear device implantation, with or without mastoidectomy |
| 70540 | Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s) |
| 70542 | Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; with contrast material(s) |
| 92587 | Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) |
| 92588 | Evoked otoacoustic emissions; comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies) |
| 92650 | Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis |
| 92651 | Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report |
| 92652 | Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report |
| 92653 | Auditory evoked potentials; neurodiagnostic, with interpretation and report |
| H81.01-H81.09 | Meniere's disease |
| H81.10-H81.13 | Vestibular disorders (range listed) |
| H81.311-H81.49 | Vertigo |
| H83.11-H83.19 | Labyrinthine fistula |
| H83.3X1-H83.3X9 | Noise effects on inner ear |
| H90.3 | Sensorineural hearing loss, bilateral |
| H90.41-H90.42 | Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side |
| H90.5 | Unspecified sensorineural hearing loss |
| H90.6-H90.8 | Mixed conductive and sensorineural hearing loss |
| H91.20-H91.23 | Sudden idiopathic hearing loss |
| S09.91xA-S09.91xS | Unspecified injury of ear [cochlear trauma] |
| Z01.10 | Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms] |
| Z01.110 | Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms] |
| No codes listed |
| No codes listed |
Prior Authorization, Documentation, and Clinical Actions
Prior authorization and benefit verification
Prior authorization and benefit verification: Providers should verify member benefit coverage and any prior authorization requirements with Aetna before performing electrocochleography (ECoG) or perilymphatic pressure measurement. Lack of verification may result in claim denial or member liability.
- Verify benefits and prior authorization with the plan prior to service
- No specific prior authorization codes or processes are stated in this policy; check payer-specific portals or provider services
No explicit coverage authorization requirements
No explicit coverage authorization requirements in this policy section: The Clinical Policy Bulletin does not state specific prior authorization or pre-authorization requirements for ECoG, intra-operative ECoG, or perilymphatic pressure measurement. However, coverage determinations depend on whether selection criteria in the policy are met.
- 92584 (Electrocochleography) is covered when medical necessity selection criteria are met
- Perilymphatic pressure measurement is listed as experimental/investigational for Meniere's disease and sudden sensorineural hearing loss
Authorization and billing actions
No explicit authorization, prior authorization, or billing denial triggers specified: The provided CPB text does not include coding-based denial criteria or mandatory authorization steps. Providers should still follow general billing rules and payer-specific administrative requirements.
- Follow standard coding/billing guidance for CPT 92584 and related codes
- Absent explicit denial triggers in the CPB, claims will be adjudicated based on documented medical necessity and benefit terms
Recommended intra-operative recording technique
Recommended intra-operative recording technique: For intra-operative ECoG during cochlear implantation, obtain baseline extra-cochlear recordings after opening the cochlea. Intra-cochlear responses may be recorded using the cochlear implant electrode (most apical contact) as the recording electrode; extra-cochlear recordings can be obtained from a promontory needle electrode.
- Baseline extra-cochlear ECoG after opening the cochlea
- Intra-cochlear ECoG can use the implant's most apical electrode as the recording site
- Tone-burst (250–1,000 Hz) and click stimuli commonly used
Required documentation elements
Required documentation elements: Include diagnostic indication, clinical rationale that meets policy selection criteria, ECoG measurements (e.g., SP/AP ratios, presence or change in cochlear microphonic/AP), intra-operative baseline and any intra-operative changes, and correlation with audiometric findings when applicable. Retain operative notes describing electrode placement and recording method.
- Document clinical indication (e.g., suspected Meniere's disease, profound hearing loss with ABR)
- Record SP/AP ratios and thresholds; note SP/AP >35% when applicable
- Log baseline extra-cochlear and intra-cochlear recordings and any intra-operative changes
- Correlate and document audiometric outcomes and follow-up findings
Provider responsibilities and disclaimer
Providers are responsible for medical advice and treatment; CPBs are partial descriptions: Clinical Policy Bulletins are tools to assist in administering plan benefits and do not replace clinical judgment. Treating providers remain solely responsible for medical advice and treatment. Deviations from the CPB or incomplete documentation may affect coverage determinations.
- CPB is a partial, general description of benefits and not a contract
- Treating providers retain responsibility for medical decisions and documentation
- Failure to document medical necessity consistent with this CPB may lead to adverse coverage determinations
Clinical Background and Evidence Summary
Meniere's disease (endolymphatic hydrops) is characterized by episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness; the disorder has an estimated incidence on the order of a few hundred per million. Trans‑tympanic electrocochleography (ECoG) evaluates inner‑ear physiology by recording the summating potential (SP) and the action potential (AP) and calculating the SP/AP ratio. An elevated SP/AP ratio has been used as an indicator of endolymphatic hydrops, and ECoG may be performed with auditory brainstem response testing to assist identification of wave I in cases of profound hearing loss (PTA ≥ 90 dB HL at 500, 1,000, 2,000 and 4,000 Hz).
inv-04 (supporting evidence overlap): Documented clinical uses / evidence — (also referenced under Coverage Criteria) used here to summarize study findings and contexts
Supporting evidence summarized for policy context
Recent literature examining intraoperative ECochG during cochlear implantation highlights technical variability and interpretive challenges. Studies report that electrode movement, recording location, stimulus parameters, and signal analysis (including phase and harmonic content) can all influence intra‑cochlear ECochG responses. Because of these heterogeneous methods and inconsistent outcome correlations, the evidence to date does not provide a standardized, reliable intraoperative ECochG metric for predicting cochlear trauma or long‑term hearing preservation.
Definitions and Key Terms
Policy Dates and Revision History
Policy underwent routine review (Last review recorded).
Policy became effective on this date.
Next routine review scheduled.
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